"We didn't do a good enough job in terms of how we crafted the law," he said in an interview with NBC News.

But a senior Republican labelled his remarks a "half-hearted apology".

During his campaign for the passage of the Affordable Care Act, also known as Obamacare, Mr Obama repeatedly insisted that people who liked their health insurance policies would be able to keep them.

'Tough position'

But it now appears that millions of people who purchased plans on the private individual market rather than receive health coverage from the government or their employers may in fact have to buy new, possibly more expensive plans.

"I am sorry that they are finding themselves in this situation based on assurances they got from me," Mr Obama said.

"We've got to work hard to make sure that they know we hear them, and we are going to do everything we can to deal with folks who find themselves in a tough position as a consequence of this."

The health law's supporters have said most people thrown off their health plans will be able to buy better insurance policies at better prices, especially those eligible for subsidies provided under the health law.

The opposition Republicans, who have fought the president's healthcare law at every turn, have seized on the reports of the policy cancellations. Some have gone so far as to accuse Mr Obama of lying to the public during his campaign for the law's passage.

Even some of Mr Obama's fellow Democrats have suggested the administration delay parts of the law's implementation, including a requirement that people carry health insurance or face a penalty.

Mr Obama's remarks on Thursday came after weeks of serious problems with healthcare.gov - a website established under the law - which allows consumers to shop for private health insurance plans.

Among other issues, it has been plagued by long wait times to sign up for an insurance plan and serious flaws on the back end where customers' data are processed and sent to insurance companies.

Mr Obama has vowed the website will be repaired.

The Republican response to Mr Obama's remarks was swift, with Senate Minority Leader Mitch McConnell saying "if the president is truly sorry for breaking his promises to the American people, he'll do more than just issue a half-hearted apology on TV".

Thursday's television interview was the latest effort by Mr Obama to win public support for the embattled healthcare law.

On Wednesday he travelled into the heart of Republican territory to talk up the measure.

"We are going to get this done," he told a crowd in Dallas, Texas.

The law's new coverage requirements for health insurance plans have been blamed for the policy cancellations.

Its other provisions include establishing the healthcare.gov website and others run by the states; mandates that individuals carry insurance or pay a tax penalty; and subsidies to assist in the purchase of the insurance.

It also expands eligibility for the Medicaid government health programme for the poor.

Poll shows California is more supportive of Obamacare than the U.S. at large, but many fear higher costs and economic damage.

Californians are more supportive of President Obama's healthcare law than the country at large, but they still worry it will raise healthcare costs and hurt the economy, a new poll of registered voters shows.

Statewide, 50% said they backed the Affordable Care Act and 42% opposed it, according to the USC Dornsife/Los Angeles Times poll. That runs counter to national polls that show more people disapprove of Obamacare than support it.

Latinos, who make up about half of California's uninsured population, were even more enthusiastic, supporting the healthcare law by a 2-1 margin. Forty-nine percent of whites were opposed, with 44% in favor.

Predictably, 77% of Democrats backed the president's healthcare plan, whereas 80% of Republicans surveyed said they were against it. Independents were more evenly split.

Cutting across partisan and racial lines, Californians as a whole were skeptical that the Affordable Care Act would live up to its name.

Sixty-five percent of respondents said people wouldn't be able to afford the health insurance they'll be required to have under the law's individual mandate. Forty percent think the program will have a negative effect on what they pay for coverage, compared with 21% who expect a positive outcome.

According to the survey, 46% of registered voters expect the Affordable Care Act to be a drag on the overall economy and 34% see an economic boost. Nearly 60% think the law's new requirements will raise healthcare costs and keep businesses from hiring more workers.

The poll was taken just as the national healthcare rollout was coming under intense criticism in Congress, even from some Democrats. Obama has apologized for the malfunctioning healthcare.gov enrollment website and for millions of Americans receiving cancellation notices because their current coverage doesn't meet all the requirements of the healthcare law.

Those consumers have directed much of their anger at Obama's repeated pledge that Americans could keep their existing insurance if they liked it.

California is running its own insurance exchange, as are 13 other states, and its online enrollment hasn't experienced nearly as many problems as the federal marketplace for 36 states. But the sticker shock from higher premiums and concerns about losing access to preferred doctors and hospitals have taken a toll.

"California has had a pretty good rollout on its exchange compared to the national one, but people here are still feeling the negative repercussions of higher costs and lost policies," said David Kanevsky of American Viewpoint, the Republican firm that helped conduct the poll for the USC Dornsife College of Letters, Arts and Sciences and The Times.

The poll was conducted jointly by American Viewpoint and Greenberg Quinlan Rosner Research, a Democratic polling firm in Washington. They surveyed 1,503 registered state voters by telephone Oct. 30-Nov. 5. The margin of error is plus or minus 3.1 percentage points, and larger for subgroups.

For Obama and his signature law, much depends on Californians embracing the changes. California wants to enroll more than 2 million people by the end of next year in subsidized health insurance or an expansion of Medi-Cal, the state's Medicaid program for the poor.

Poll respondents said they were upbeat about the law's potential to help many of the state's 7 million uninsured. Sixty-five percent expect there will be fewer people without coverage and 67% think patients will get more access to checkups and other preventive care.

"Fundamentally, Californians are viewing the Affordable Care Act as a mixed bag," said Drew Lieberman of Greenberg Quinlan Rosner. "They harbor real concerns about the potential negative impact on costs and the economy."

Diana Sackett, 61, a software engineer in Pleasanton, has many of those worries even though she strongly supports the president's healthcare plan. She has battled cancer in the past and knows the value of quality health coverage. "In an advanced country like ours, everyone should be able to get the healthcare they need," Sackett said.

But she isn't optimistic that the healthcare law will stem the rising costs of medical care and fears it may even get worse with an influx of newly insured patients.

"I'm concerned it won't really address the cost problems," said Sackett, who pays for health insurance through her employer. "I think healthcare is still going to be pretty expensive."

According to the poll, the changes are being implemented at a time when voters are generally satisfied with their own healthcare. Ninety percent of respondents said they were happy with the quality of their medical care and access to their doctors.

Sunday, November 3, 2013

Many House Republicans are replacing their push to delay or defund the 2010 federal health law with a new strategy: Hang back and see if problems with the rollout continue or get worse.

It is an abrupt reversal of the activist approach of just weeks ago, when Republicans demanded changes to the law in exchange for funding the government or raising the nation's borrowing limit. Now, they say putting the spotlight on technical flaws of the law's health-insurance exchange may be more effective than a direct attack.

Rep. Michael Burgess (R., Texas)

"It's its own worst enemy, and to some degree it is collapsing under its own weight," said Rep. Michael Burgess (R., Texas), who sits on the committee that pressed Health and Human Services Secretary Kathleen Sebelius on Wednesday to explain what is going wrong.

Weeks ago, Democrats had been unified against GOP efforts to delay parts of the law, particularly the requirement that people carry insurance or pay a penalty. But now, as problems in the rollout of the law prompt some Democrats to call for a delay, it is Republicans who say they are giving up on changing anything.

"There are folks in my caucus who say just let the Americans face the pain," said Tim Huelskamp (R., Kan.), who voted recently to link government spending to a one-year delay of the health law. Now, he says the fate of the law is out of the hands of Congress. "At this point in time I don't think we can change anything," Mr. Huelskamp said.

Democrats see the approach, which focuses on oversight hearings, as a not-so-veiled attempt to undermine the Affordable Care Act. "They hate this law," Sen. Dick Durbin (D., Ill.) said of GOP lawmakers. "They want it to fail. They're praying for chaos to affirm their suspicions that it's the wrong thing for America. Now, when they criticize the rollout as not being smooth and not being fair to the American people, it rings hollow."

Many Democrats say that once problems with the website are ironed out, Americans will see the law as an improvement.

One wing of the Republican Party has favored confrontation over the health law, while the current strategy shows the more pragmatic wing reclaiming the upper hand. Indeed, Republicans who have watched House Speaker John Boehner (R., Ohio) for years say the approach is consistent with one of his political philosophies: If you perceive your opponent to be committing suicide, get out of the way.

"It's nonconfrontational: Here's your law, have at it. And things aren't going very well," said former Ohio Rep. Steve LaTourette, who was a close ally of Mr. Boehner's and is the head of the Republican Main Street Partnership, a centrist group.

There is a risk of new intraparty fights early next year, when government spending must be renewed and the borrowing ceiling must be raised again. And some Republicans still prefer trying to vote the law out of existence. "We've got to delay it until we repeal it," said Rep. Paul Broun (R., Ga.). "We've got to do everything we can."

Other House Republicans prefer to focus on boosting oversight of the law. On Thursday, House Oversight and Government Reform Committee Chairman Darrell Issa (R., Calif.) said his panel issued a subpoena to Ms. Sebelius for documents related to the exchange website.

Republicans are speculating that Mr. Obama will have to delay the requirement that people carry health insurance. Last month, the administration effectively extended the deadline for Americans to avoid a penalty, giving them until March 31, but it has said the website will be fully functioning by the end of November and that there is no reason to discuss a delay.

Such a further delay would have real effects, according to David Axene, a fellow with the Society of Actuaries. Potentially, it could prompt younger people to forgo coverage and leave insurers to cover mainly older people, which could, in turn, lead to higher rates.

Some Democrats say that is why they are focused on making the online exchange work. "When you start making changes that particularly go to the question of being able to predict, for example, what premiums will be, it's got great implications," said Sen. Ron Wyden (D., Ore.).

The Affordable Care Act will open doors for more patients to get treatment, but resources may not be there to meet the demand in states such as Delaware.

Tricia Hill gave up trying to get health insurance years ago.

The 39-year-old Newark resident spent two decades in the throes of a chronic mental health disorder, a condition that made it hard for her to hold a job and easy for insurance companies to reject her applications for coverage.

"It seemed like it was hopeless," said Hill, who declined to detail her condition.

So she relied on disability benefits.

That's about to change dramatically for Hill and thousands of other Delaware residents, as the Affordable Care Act, also known as Obamacare, makes it illegal for those with pre-existing conditions to be rejected for coverage -- and mandates mental health care coverage starting in 2014.

But just because you'll be entitled to the services doesn't mean you'll get an appointment -- at least not a quick one in Delaware, which has a shortage of mental health practitioners, according to the U.S. Health Resources and Services Association.

"There is no way we can serve all of them," said Dr. Ranga Ram, a psychiatrist in Brandywine Hundred, who expects far more emerging patients than the system can absorb, with some estimates putting the number at 30,000. "The hope is that they will stagger in over a period of three or four years."

The number of working psychiatrists in Delaware is hard to come by. The number who are accepting new patients is even more elusive. The state Division of Professional Regulation reports 113 licensed psychiatrists in the state, but some are retired and/or not accepting new patients.

New avenues will have to open, Ram said -- for therapists, advanced practice registered nurses and others -- and more collaboration with primary care physicians will be needed.

But coverage starts in two months, and the gaps in the system will be enormous.

Effective treatment can have profound implications for those who need the care. When their condition is stabilized -- as Hill's now is -- they can get and keep better jobs, avoid medical problems triggered by unaddressed mental health conditions and avoid situations that lead to criminal charges and/or jail.

Over capacity

Federal officials estimate that one in four people with no insurance have mental health or substance abuse conditions. They expect 32 million new patients to seek care under the new law.

In Delaware, which has an estimated 90,000 uninsured residents, that would mean about 22,500 with potential need for care -- not counting those who already have some kind of medical insurance but none for mental health or substance abuse.

Dr. Ranga Ram

Meanwhile, Delaware's mental health system is already over capacity, psychiatrists and others in the field say, sometimes leaving patients to wait three or four months for an appointment with a psychiatrist.

"We've had a pinch in supply and demand all the way along the line," said Dr. Michael Marcus, director of outpatient services in psychiatric and behavioral health for Christiana Care.

Christiana Care is expanding its approach to mental health care, and the state has been aggressive in its expansion of community-based care to comply with requirements of a 2011 settlement with the U.S. Department of Justice.

The Department of Justice settlement is an important part of the context, because its 2009 investigation found that the "vast majority" of patients at the Delaware Psychiatric Center should be living in the community, not in the state's largest psychiatric hospital. The state is required to make sweeping reforms to support community-based care.

A growing network of service and support is emerging statewide -- crisis services, drop-in centers, peer supports and mental health services.

Still, according to 2012 data from the Kaiser Family Foundation, only about 39 percent of the state's need is met at current levels.

"We have under-supply and a mismatch in distribution," Christiana's Marcus said. "Fortunately, we've had some lead time to work on this. We're hiring behavioral health care professionals on an ongoing basis and we're in close consultation with state officials to coordinate our plans. … We have to step up all of our games."

To address more severe shortages in rural areas, Lewes-based Beebe Healthcare now has a partnership with In-Sight Telepsychiatry, offering its staff video consults with psychiatric specialists. That capacity is available in the emergency department and on the hospital floors, according to Beebe spokeswoman Sue Towers.

In addition to Beebe, In-Sight is providing telepsychiatry services to Kent-Sussex Counseling in Dover and Crossroads of Delaware in Wilmington, and recently established a partnership with Resources for Human Development (RHD) for its programs in New Castle and Kent counties, said In-Sight account executive Dan Khebzou.

Marcus said another good expansion strategy is the use of "physician extenders" -- advanced practice registered nurses, for example -- who can assist with evaluations and medications.

But the best strategy is finding ways to integrate mental and medical care, Marcus said.

"Behavioral health care and medical-surgical services have been somewhat siloed," he said. "It's not just more treatment that is needed, but treatment that will improve people's health care," he said. "We have to really keep adding capacity and in a smart way. … So it's not necessarily more of the same, but in a more innovative way."

Christiana Care's decision to embed a psychiatrist in its cardiac center is an example, Marcus said. A person with an undiagnosed anxiety disorder may arrive at the hospital in a full panic attack, with symptoms indistinguishable from cardiac distress, he said. They would get a full cardiac "workup" to find out what's going on medically, Marcus said.

Having a psychiatrist available for a mental health consultation makes it possible to diagnose psychiatric problemswith greater accuracy and treat the patient more effectively.

Removing barriers

The Affordable Care Act removes several artificial barriers to care, psychiatrists Marcus and Ram said. Refusal to cover those with mental health problems will be illegal, and some limits to care have been removed, too. A 20-visit cap on therapy sessions, for example, will be gone, though Linda Nemes of the Delaware Insurance Commissioner's office says all care will be reviewed and managed as it unfolds.

Nemes said health insurance issuers Highmark and Coventry were required to certify an adequate network of providers to gain the marketplace contracts in Delaware. The state will monitor performance to be sure those requirements are met, she said.

The new coverage may open new doors for Hill, who is working part-time as a peer specialist to help others with mental health conditions gain traction in their recovery. Under present rules, she can't take on additional responsibilities or get a full-time job because she must keep her monthly income at or below $1,040 or lose her disability benefits.

If she can get the health care she needs through the Affordable Care Act, she may be able to live her dream -- finish her college degree, get a master's, and become a full-time social worker.

"I've made a lot of progress," she said. "I was at a point where I was completely unable to function without a lot of care. I received a lot of assistance. Now, I'm at the point where I have almost no assistance.

"I've come a really long way. I decided to take personal responsibility for my own recovery and started working toward making that happen."